In addition to general health and wellness, exercise is an essential element to blood glucose regulation in patients with diabetes mellitus.

Studies have found the benefits of exercise include decreased body mass index (BMI), lower hemoglobin A1C levels, reduced diabetic ketoacidosis (DKA) rates and fewer comorbidities such as dyslipidemia, retinopathy and microalbuminuria.

“Exercise is the key component of diabetes management and complication prevention,” said Ryan J. Dyess, M.D., who recently completed his tenure as the Norah Price fellow in pediatric endocrinology at Norton Children’s Endocrinology, affiliated with the UofL School of Medicine.

Dr. Dyess presented during a recent continuing medical education opportunity, “Diabetes and Exercise,” at the sixth Wendy Novak Diabetes Symposium.

Researchers looking at individuals with diabetes mellitus also have found exercise has significant benefits for mental health, according to Dr. Dyess. He focused on patients who would benefit from this research with Bradly J. Thrasher, D.O., MBA, who sees patients at the Wendy Novak Diabetes Institute, a part of Norton Children’s Endocrinology, and is lead physician at the Christensen Family Sports & Activity Program.

“They found that exercise improves self-esteem and overall mental health, with significant improvements in many other factors as well, including anxiety and insomnia,” Dr. Dyess said.

Exercise and standard of care

The American Diabetes Association (ADA) has taken a position strongly in favor of physical activity and exercise: “The adoption and maintenance of physical activity are critical foci for blood glucose management and overall health in individuals with diabetes and prediabetes.”

The ADA’s standard of care calls for children and adolescents having a goal of 60 minutes of moderate to vigorous aerobic activity every day and vigorous muscle- or bone-strengthening exercise at least three days per week.

The Christensen Family Sports & Activity Program, part of the Wendy Novak Diabetes Institute at Norton Children’s Endocrinology, is geared toward children, adolescents and young adults living with Type 1 diabetes who want to improve fitness and performance and get more in tune with their glucose control management.

The program includes endocrinologists, exercise physiologists, a registered dietician nutritionist and a dedicated diabetes educator. They collect data on the timing of food intake and insulin dosing, sleep habits, performance records, and blood sugar levels before, during and after exercise.

“We use all this data to provide recommendations, guidance and education as needed to provide the patient with the best diabetes management plan they can have moving forward,” said Dr. Thrasher, who is also an assistant professor of pediatrics in the Division of Endocrinology at the University of Louisville School of Medicine..

These individualized care plans can be shared with trainers, coaches and others so they know what the athletes’ blood sugar levels are before they participate, as well as the changes the patients are making to their insulin pumps before and after activity. The plans offer guidelines to make sure athletes are in safe ranges.

The program also helps athletes with Type 1 diabetes compete at the highest level. A low blood sugar level can hurt performance.

“Our team evaluates the athlete’s physical needs to provide an individualized plan to enhance their sport or everyday performance,” Dr. Thrasher said.

Reducing exercise risk for those with diabetes

Exercise does have the potential for adverse events in individuals with diabetes.

The Diabetes Research in Children Network (DirecNet) Study Group found aerobic exercise produced frequent hypoglycemia during exercise and nocturnal hypoglycemia after exercise.

In people who do not have diabetes, exercise increases glucose in muscles actively working out, leading to decreased plasma glucose, followed by insulin getting turned down and counter regulatory hormones getting turned up, according to Dr. Dyess.

“In an individual with diabetes, you can’t turn down the amount of insulin. Thus, your counterregulatory hormones are also not as high,” Dr. Dyess said.

The excess insulin and lower levels of counterregulatory hormones lead to low blood sugar levels.

A multicenter study, however, found severe hypoglycemia — requiring glucagon or additional assistance — was no more common in active adults with Type 1 diabetes than those who were not physically active.

Exercise also can pose a risk for those with hyperglycemia and moderate or large ketones. Individuals with diabetes should check their ketones prior to exercise if they have hyperglycemia. Ketosis could worsen during strenuous activity, particularly in an athlete who doesn’t have insulin on board, according to Dr. Dyess, who has Type 1 diabetes.